It is crucial to discuss the demand side but what i feel good is to look at the health sector as a whole and put some ideas on the demand side of it. In most developing economies/countries the major bootle neck is the institutional structure of the sector.If we take most of African countries the sector is gloated at the ministrial level but thin in the areas of beneficialries.that is to say we do not see the normal shape of a triangle but an inverted nature of a triangle. Let i bring an example from my experience,Ethiopia, the federal ministry of health is well favored in terms of budget,human resources and services while the regional offices are lingering with scarce resources as well as timeliness and if we go to the last hierarchy of the ministry which are the beneficieries have scarce resource in terms of human capital,finance,communication etc. what i want to incite above is that even if different donors,borrowers and philantropists contribute for the health sector due to the ill health policy of the country the trickle down of resources could not fullfil the needs or wants of the rural population. We can say that if we have to bring change in the health sector in the country it is better to invest in human capital who are willing to serve at grass roots as well design our policy to reward those who serve in the rural areas because currently what is happening is that people who have access to all facilities (living in relativey big towns) are also well rewarded with renumerations as well kick backs from national/international procurements,seminars and the like.

Thanks for posting an updated version of the e forum the weeks 1,2,3 and 4. For the week comments on resistance to scale up on demand side. There are many reasons for which this can be. for example if where difficulty exist because fund can not be access may be proposal format is not follow or procedure and process is not well adhere to. and many cases of operating activities that organization did not buy into, it will be difficulty to scale up such an activities. We should not all forget the pillars of PHC, which is affordable and CULTURALLY ACCEPTABLE METHODS AND TECHNOLOGY made available to where people in their c om munities.

The Consortium for Street Children is the only worldwide network that works collectively to help street children on a global scale. Street children, according to the World Health Organisation, are particularly vulnerable to HIV/AIDS/STDs because of the characteristics of street life: vulnerability to sexual abuse, unprotected sex, early sexual initiation, and injecting drug use. Despite this acknowledged vulnerability street children remain the excluded face of HIV/AIDS. In 1992 an advisor to the Pan American Health Organisation wrote: “As we advance in the second decade of the AIDS pandemic, and despite the wealth of behavioural research on the subject, we are confronted by the fact that one particular subpopulation, that of homeless youth, has received little attention in regard to their risk of exposure to HIV infection and other sexually transmitted diseases […] Street youth are often not included in traditional institutional networks for providing health care and social services.” (Lydia S. Bond, Regional Advisor on Behavioural Interventions and Special projects for the Prevention of HIV and STD). 16 years on the situation remains the same. Street children worldwide continue to have little or no access to HIV/AIDS services. For example, in St. Petersburg, street children who tested positive for the virus were turned away from government-run health clinics because they lacked documentation. There is a real demand for street children to access both preventative and basic health services. The problem is that these children, and those that work with them, are extremely under-resourced and under-represented in society so their voices are never heard. If the Global Fund truly wants to ‘listen to the voices’ you must include the concerns of street children in order to fully meet the needs of those affected by HIV/AIDS. Their exclusion from the debate on HIV/AIDS creates a real obstacle to the translation of needs into programs that address the global epidemic. The Global Fund, through its Country Coordinating Mechanisms, should aim to build the capacity of NGOs and grassroots organisations, which provide targeted information and services about HIV/AIDS to street children. Such organisations need technical support and long-term funding to enable them to develop supportive knowledge, skills and attitudes for street children worldwide, but also to have the capability and capacity to advocate on behalf of street children on HIV-related issues. It is vital that street children gain access to HIV-related services and that greater awareness of sexual and reproductive health issues, including prevention, among street children is increased. Otherwise, the pledge for universal access to treatment by 2010, and the pledge to reverse the spread of the epidemic by 2015 will never be reached.

What factors in terms of capacity are preventing adequate scale-up to meet demand and what could the Global Fund and/or its partners do to overcome them? FACTORS: - Manpower resources - Inadequate staff - Inadequate skilled manpower relative to different stages. Equipment – Limited and problem of maintenance. Workers welfare problem: - Inadequate remuneration - unpaid staff claims - owing of salaries - industrial unrest - Industrial Health: - Workers illhealth, lack or poorly managed staff clinic - Lack of staff canteen, poor feeding and weakness of staff. - Frequent industrial accidents - Raw materials: - scarcity of materials - High cost of materials - Difficulty in securing loans to buy materials as a result of bad debts, Government policy etc - Poor Implementation: - Most areas that really need support do not get it. - Host community problems:- Restiveness of the host community – aggression. TO OVERCOME THE PROBLEMS: - Situation analysis and proper planning. - Improve public relations – community dialogue - Staff welfare package – Bonus awards, good staff canteen, staff clinic and better services, improved salaries. - Employment of more staff - Improved staff skills – capacity building: continuous training, refresher training, on the job training. - Appropriate job placing - Machinery – Routine servicing of equipment. - Avoidance/Minimizing Industrial Accidents – Safety wears, environmental control - Raw materials – Provision of materials - Release of adequate funds - While implementation is going on, intensify monitoring and evaluation for appropriate review

The Global Fund should perform a SOWT analysis (Strengths, Opportunities, Weaknesses and Threats) of its implementation model which should have very low operational costs since it doesn’t have in-country offices.

It would be important to assess the cost-benefit relation in the scale-up of programs, where at present the model used gives priority to the financial accountability (for the execution of activities) while neglecting the vision of the overall program. The LFA does not manage issues of programming, so little value is placed in the processes that are as important as the results that can be achieved for the control of any of the diseases.

One possibility would be to form a regional or sub-regional cluster with the aid of technical partners so that they support, supervise and follow-up the execution of programs like the ones for TB or HIV.

Regarding the challenges, most of our countries in this region have a health structure with many weaknesses and even if we consider that there is room for improvement, the scale-up of processes in health system reform has only further weakened the national programs.

Regarding infrastructure: Dominican Republic has good capacity.

The weaknesses are in the scale-up of the model used and the quality of service. Donors, like the Global Fund, must address the design and execution of human resource policies as part of the health systems strengthening. Work instability due to political changes, lack of attention to training of human resources, low salaries and high staff turnover, are a few of the limitations.

This reality must be acknowledged so that countries can receive funds to design and execute actions that strengthen the overall health system; or at least to give priority to simple strengthening of vertical programs, aiming to slowly integrate them into the rest of the system.

Existing regulations regarding the procurement and distribution systems are not used in a coherent manner.

Countries should continue to have a say in the way requested funds are spent, but donors that understand the country weaknesses should also establish requirements for the delivery of these funds (read full post by Ivelisse Acosta, Dominican Republic).

Dear e-Forum participants, 

We have received a number of interesting posts for this week's question in this forum, and I would like to thank all who have participated so far. To further develop the ideas that have emerged from discussions, I would like to share with you the summary of posts from the Russian forum.  

-          Challenges: The lack of coordination between sectors in the fight against HIV/AIDS; lack of compassion and a human approach. Recommendations: Use a case-by-case approach towards working methods of governmental and non-governmental organizations for services targeting PLWHIV; ensure free access to testing; increase tolerance in society and the capacity of health workers; establish the level of fees charged for keeping PLWHIV in hospitals to give incentive to medical institutions to provide them with treatment; allot funds to centers for psychological support and palliative care for PLWHIV; allot resources to the prevention and treatment of other diseases (read full post by bakster, Lithuania).

-          Challenges: The surge of organizations that negate the existence of AIDS and hamper the implementation of HIV preventative programs; lack of government support and the channeling of grants into the wrong hands; lack of information on donors (read full post by Alina Savina, Russia).

-          Challenges: The impossibility of re-allotting funds given to a certain project. Recommendation: The time from when the grants are signed and program implementation is very long, during which the situation in the country can change quite significantly. The Global Fund should review the rules under which changes in the project should not exceed 10% of the amount approved, and provide other means of distribution of funds from voting within the CCM (read full post by Мurad, АAzerbaijan).

Keep the contributions coming!

Alastair
E-Forum Facilitator

Hi Okonta,

This week’s question is, as you have rightly pointed out, not a question of funding, but what is stopping the funding available getting to where it is needed in the countries (i.e. demand). Thank you for you participation – and to all who have participated on the question of capacity and demand so far – I look forward to reading more of members’ perspectives on this interesting issue!

Best regards,

Alastair
e-Forum Facilitator

 

SCALING UP CAPACITIES    

HIV/AIDS has for all intents and purposes become a sub Saharan African problem. The reasons why this is so is not necessarily for want of  resources. TO my mind, the major problem is IGNORANCE. It is ignorance that leads to misapplication of scarce resources. It is also the reason why leadership prefers wastages and pilfering   to working for the good of the people whom they pretend to be leading. On the other side is the inability of people to accept scientific facts as truth without superstition. IT is the acceptance of these fac ts that will lead to behavioral change which is so necessary in HIV/AIDS prevention. This is the difference between the western societies and Sub Saharan Africa. Despite wide spread knowledge and information on HIV/AIDS, people still carry on as if it does not exist.

                                  IT may be good therefore for the GLOBAL FUND to specifically target those religious institutions that meet people’s  religious yearnings. Often they are the ones who first offer prayers and advice before people are brought to medical facilities fbr attention. WE NEED THEIR MAXIMUM CO-OPERATION  for success in prevention programming.THEY NEED TRAINING,INFORMATION UPDATES,GOOD COMUNICATION SKILLS ETC

TREATMENT failures have not as at now been addressed by most national programmes. ITS existence is not in question. IT appears that we are beginning to accept that death is inevitable,” somehow”. Continues treatment is hampered by lack of adequate laboratory  facilities. TESTING for drug resistance is not available. WE can not as of now talk about  viral copies, not to talk of typing the virus. Even doing CD4 count is with difficulties.

WE need these facilities to be provided in strategic locations where health care providers can have access to them.

 

PERSONNEL DEVELOPMEhNT is needed for a focused treatment programme. This training should involve the private medical practitioners who in most cases see the bulk of the patients. The GLOBL FUND can fund  NGOs who will be used to continuously upscale the knowledge of the care givers.

 

A few cases in point,

- 96% of persons tested for HIV in Cameroon in 2007 did not retrieve their results (UNGASS progress report no. 3). The weak link: poor pre-test counselling mostly due to a lack of adequately trained counsellors in the health system and in the community.

- ARV are essentially free of charge but the problem of distance to treatment centres (which translates to cost of transportation) to collect their prescriptions is commonly cited by patients as a reason for non adherence